Time-varying effects of 'optimized smoking treatment' on craving, negative affect and anhedonia

Abstract

Aims: To identify when smoking cessation treatments affect craving, negative affect and anhedonia, and how these symptoms relate to abstinence, to help evaluate the effects of particular intervention components in multi-component treatments and accelerate treatment refinement.

Design: Secondary analysis of data from a two-arm randomized controlled trial.

Setting: Seven primary care clinics in Wisconsin, United States.

Participants: Adult primary care patients who smoked daily (n = 574).

Intervention and comparator: Intervention was abstinence-optimized treatment (A-OT, n = 276) comprising 3 weeks of nicotine mini-lozenges pre-target quit day (TQD), 26 weeks of combination nicotine patch and mini-lozenges post-TQD and extensive psychosocial support. The comparator was recommended usual care (RUC, n = 298), comprising brief counseling and 8 weeks of nicotine patch post-TQD.

Measurements: Time-varying effect models examined dynamic effects of A-OT (versus RUC) on the primary outcomes of nightly cigarette craving, negative affect and anhedonia from 1 week pre- to 2 weeks post-TQD. Exploratory models examined within-person relations between nicotine medication use and same-day symptom ratings. Secondary logistic regression analyses examined associations between post-TQD craving, negative affect and anhedonia and 1-month post-TQD abstinence.

Findings: A-OT significantly suppressed pre- and post-TQD craving (β = -0.27 to -0.46 across days) and post-TQD anhedonia (β = -0.24 to -0.38 across days), relative to RUC. Within individuals, using patches was associated with lower negative affect in RUC (β = -0.42 to -0.52), but not in A-OT. Using more mini-lozenges was associated with greater craving (β = 0.04-0.07) and negative affect (β = 0.03-0.05) early, and with lower anhedonia (β = -0.06 to -0.12) later. Greater post-TQD craving (OR = 0.68) and anhedonia (OR = 0.85) predicted lower odds of abstinence 1 month post-TQD.

Conclusion: Time-varying effect models showed that a multi-component treatment intervention for smoking cessation suppressed significant withdrawal symptoms more effectively than recommended usual care among daily adult smokers motivated to quit. The intervention reduced craving pre- and post-target quit day (TQD) and anhedonia post-TQD.

Keywords: Multi-phase optimization strategy; nicotine replacement therapy; smoking cessation; time-varying effect modeling; treatment refinement; withdrawal.

Figure 1.. Timeline of study phases, ecological momentary assessment, and treatments by treatment condition

^a Participants were encouraged to use the full-course of medication, regardless of whether they had returned to smoking (unless they experienced intolerable side effects). ^b In RUC, Session 1 (S1) involved a face-to-face counseling session of 10 minutes, fax referral to the Wisconsin Tobacco Quit Line, and instruction in downloading the QuitNow smartphone app. ^c In A-OT, Session 1–3 (S1-S3) were 20-minute face-to-face counseling sessions. ^d In A-OT, Calls 1–8 (C1-C8) were 15-minute counseling calls. ^e In A-OT, all participants received the first 7 automated calls to promote medication adherence (shown in bold); only those who were still smoking at week 8 received automated calls 8–11.

Figure 2.

Time-varying associations between Abstinence-Optimized Treatment (A-OT) vs. Recommended Usual Care (RUC) and (a) craving, (b) negative affect, and (c) anhedonia, with corresponding 95% confidence intervals (dotted lines) from 1 week pre-TQD to 2 weeks post-TQD.

Figure 3.

Mean number of mini-lozenge used in A-OT during 1 week pre-TQD and 2 weeks post-TQD and rates of patch use in A-OT and RUC during 2 weeks post-TQD.

Figure 4.

Time-varying main effects of within-person daily patch use on (a) craving, (b) negative affect, and (c) anhedonia from the TQD to 2 weeks post-TQD. 95% confidence intervals are indicated by dotted lines in all panels.

Figure 5.

Simple time-varying main effects of patch use on negative affect by treatment condition. Days on which there were significant interaction effects are the days within the black rectangle. 95% confidence intervals are indicated by dotted lines.

Figure 6.

Time-varying main effects of within-person daily mini-lozenges use on (a) craving, (b) negative affect, and (c) anhedonia from 1 week pre-TQD to 2 weeks post-TQD. 95% confidence intervals are indicated by dotted lines in all panels.

Figure 7.

Simple time-varying main effects of within-person daily mini-lozenge use in A-OT on (a) craving, (b) negative affect, and (c) anhedonia by patch use over 2 weeks post-TQD. Days on which there were significant interaction effects are the days within the black rectangles. 95% confidence intervals are indicated by dotted lines.